APPLICATION

FORM 2019
APPLICATION
NO:19010400353

Personal Details :
Name MS VANSHIKA BANSAL
Mobile No. +91-8218648950
Nationality INDIAN
Social Status GENERAL
Blood Group B+
Email Address NEERAJ.BANSAL891@YAHOO.COM
Date Of Birth 27/11/2000
Gender FEMALE
Alternate Email Address NEERAJ.BANSAL891@GMAIL.COM
Are you Differently Abled ? NO Nature Of Deformity : Percentage Of Deformity :

Preference Details
# Specialization Preference Campus Preference Test City Preference
B TECH - CSE W/S IN INFORMATION
1 SRM IST, MAIN CAMPUS (KATTANKULATHUR, CHENNAI) AGRA
TECHNOLOGY
2 B TECH - CSE W/S SOFTWARE ENGINEERING SRM IST, MAIN CAMPUS (KATTANKULATHUR, CHENNAI) ALIGARH
3 B TECH - CSE W/S BIG DATA ANALYTICS SRM IST, NCR CAMPUS, DELHI NEW DELHI

Address Details:
Address A-6/262 KAMLA NAGAR AGRA Pin Code : 282005
Country Name : INDIA State : UTTAR PRADESH District : AGRA Town/City: AGRA

Family Details:
Father Mother
Name NEERAJ BANSAL NAINA BANSAL
Mobile Number +91-9412509626 +91-8279808462
Email Address NEERAJ.BANSAL891@YAHOO.COM

Educational Details:
SSC Details (10th) HSC Details (12th) : 12TH APPEARING
Institute Name ST. PATRICKS JUNIOR COLLEGE AGRA MILTON PUBLIC SCHOOL AGRA
COUNCIL OF INDIAN SCHOOL CERTIFICATE
Board CENTRAL BOARD OF SECONDARY EDUCATION (CBSE)
EXAMINATION (CISCE/ICSE)
Scheme PERCENTAGE
Percentage / CGPA 78
Year Of Passing 2017
Registration No. 6457627

Payment Details
Transaction ID 108542140561
Payment Date 25/03/2019
Mode Of Payment Net Banking

Declaration
I certify that the information submitted by me in support of this application is true to the best of my knowledge and belief. I understand that
in the event of any information being found false or incorrect, my admission is liable to be rejected/ cancelled at any stage of the program. I
undertake to abide by the disciplinary rules and regulations of the institute.

VANSHIKA BANSAL

25/03/2019